Mental disorders in epilepsy

with the bright psycho-sensory symptoms and the liberation of protopathic affectivity K.A. Novlyanskaya (1945) explained by the disturbances of temporal-parietal-thalamic correlations. Acute delirium with epilepsy acknowledged not as the specific, but universal syndrome, which characterizes the sharpness of the course of disease (F.I. Brodskiy, 1949).

With the similarity to the same in the schubweise schizophrenia was indicated the smaller duration of epileptic stupor and the absence in the cases of delusional disorders with epilepsy, typical to schizophrenia, abstracting from the life experience of the patients (A.A. Perelman, 1944).

Interesting is the fact that the authors, who defend the right of existence of the terms of shizoepilepsy and epishizophrenia, note the exceptional rarity of the corresponding forms (P.G. Metsov, A.E. Dvirskiy, 1986; E.A. Nesterova, 1987, and others).

It was also noted that in connection with the specific personal special features the patient with epilepsy more frequently than the patient with schizophrenia, succeeds in being marked off from its delusional relation to anything and “lead a double life” (J.H. Bruens, 1971; V. Dober, 1971).

The authors of the 19th century, who were not experienced in the nosologic and anti-nosologic theories of our time, without the shadow of doubt described what they saw, and including deliusional and catatonic disorders with epilepsy, indicating in this case the unfavorable prognosis (P. Butkovskiy, 1834; P.P. Malinovskiy, 1847; I.M. Balinskiy, 1859; V. Griesinger, 1867). I.M. Balinskiy, for example, considered that “generally the insanity can complicate all illnesses, and this rule is subject to no exception”.

For the sake of fairness it should be noted that eqully confident were our contemporaries E. Slater and A. Beard (1963), who diagnosed in 69 cases chronic epileptic shizophrenia-like psychosis, taking into account characteristic for temporal epilepsy data of electroencephalographic of study.

In recent years were carried out comparative studies of patients with the epileptic psychoses and patients with the psychoses without the diagnosis of epilepsy.

E.J. Clarke et al. (1997) for the development of the differences between those (n=31) and others (n=40) used check list of operating criteria and computer program for the classification of psychotic states. The authors established that the patients with the psychosis with-

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out epilepsy more frequently have “family history of psychosis”, and in patients with the epileptic psychosis considerably more frequently is diagnosed “large depression”. In the opinion of authors, psychoses, connected with epilepsy, have different designations and “some cases of temporal epilepsy are, apparently, connected with the positive symptomatology of schizophrenia”.

B.H. Landgrebe (1997) considered equally frequent in the epileptic psychosis and the schizophrenia the structural deviations of temporal lobe with the disturbance of metabolism and blood circulation.

T. Sakai et al. (1997) compare the phenomenon of “false realization of physical presence” (K. Jaspers, 1913) in 11 patients with temporal epilepsy and in 11 patients with the schizophrenia and their characteristics are the following. The object of “physical presence” with the schizophrenia is “someone”, and with epilepsy

– “something”. With schizophrenia the distance from the patient to “the object” behind composes several meters, while with epilepsy – in the limits of one meter. With the schizophrenia “physical presence” is manifested in the insidious (being stolen up) manner and remains for more than several weeks, while with epilepsy it appears paroxysmal and disappears within the limits of one minute. Furthermore, “physical presence” with the schizophrenia more frequently connect with the development of the delusion of persecution and openness, while with epilepsy it more frequently occurs together with the paroxysm of fear.

On the basis of the results of the carried out comparison of the neuropsychological profiles of patients with the schizophrenic psychosis (n=22) and patients with the shizophrenia-like epileptic psychosis (n=25) J.D.C. Mellers et al (2000) do not support hypothesis about a difference in the pathophysiology of indicated psychotic disorders. In the opinion of the authors, important role in the appearance of each psychoses similarly plays the anomaly of dominant temporal lobe with similar for all patients cognitive decrease and scarcity of attention.

According to O. Devinsky et al. (1991), O. Devinsky (1995), L. Berzen (1999), outcome of chronic psychoses with epilepsy are more favorable than with schizophrenia, patients with the chronic epileptic psychosis more rarely are hospitalized and more rarely need treatment with neuroleptics, in their clinical picture predominate visual, but not auditory hallucinations, they do not have gross changes in the personality and emotional coldness as with the schizophrenia.

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Idea about the existence of the so-called biological antagonism between these two nosologic forms up to now still resists the search for the reasons for the isomorphism of productive psychopathological and neurupsychological disorders with schizophrenia and epilepsy. One of the systems proof of the lawfulness of establishing the clinical similarity between the schizophrenia and the psychotic manifestations of epilepsy is the concept of united psychosis, the assuming generality of the pathogenetic mechanisms, affected not only in the process of ontogenesis, but also in the process of the self-development of disease (A.V. Snezhnevskiy, 1983).

However, the stably high level of primary disability and difficulty, unavoidably appearing with solving the questions of the rehabilitation of the patients with schizophrenia and with epilepsy, require the examination not of similarities, but mainly nosologic differences in their clinical expression, flow, pathogenesis and prognosis.

The purpose of study was the evaluation of most general regularities in the development of schizophrenia and epilepsy, and also basic differential-diagnostic clinical and prognostic criteria of schizophrenic and epileptic psychoses based on an epidemiological study.

In the course of the epidemiological study we compared two groups of adult patients, which were under the observation of the clinic department of the Orekhovo-Zuevo psychiatric hospital: the first group consisted 451 patients with schizophrenia (216 men, 235 women); the second – 329 patients with epilepsy (211 men, 118 women), in whom at least once in the lifetime were noted psychotic disorders. The data about the duration of disease, type and stage of its course, nature of the leading psychopathological syndromes, frequency of hospitalizations were included in the card of epidemiological experiment besides the information about the age, the formation, the profession of patients.

For the classification of the studied psychopathological disorders were used the developed by us dynamic and structured characteristics of epileptic psychoses and the dementias, the definitions, which are contained in the division of schizophrenia in the adapted for the use in the domestic practice version of ICD-9 (1982), and also the systematic recommendations regarding the conducting of a comparative epidemiological study of forms of schizophrenia and its course (L.Ya. Uspenskaya, 1982).

The data obtained in the course about the unauthenticity of differences in the structure of predominating in the clinical picture

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of schizophrenia and epilepsy registers of productive psychopathological disorders indicated the representativeness of the compared groups of patients. Psychoses with the predominance of affective disturbances in the patients were observed in schizophrenia in 37,7% of cases, in the patients with epilepsy – in 35,3%. Psychoses with the predominance of delusional manifestations were noted respectively in 38,4 and 34,9% of cases, while psychoses with the presence of catatonic disorders – in 25,9 and 29,8% of cases.

These data sufficiently convincingly confirm the existence of the clinical isomorphism of the studied forms of pathology. At the same time they do not contradict that with the practically equal lifetime in both groups of patients were discovered the reliable (on Student’s criterion) group differences at the age of patients both in the period of the appearance of the first signs of disease and in the period of evaluation. In the population of the patients with epilepsy reliably more frequently the disease began at the age of up to 20 years and reliably more frequently than with the schizophrenia, in the period of evaluation, were encountered the persons younger 30 years. Appeared in this case tendency toward the later demonstration of schizophrenic psychoses, in our opinion, can serve as occasion for the intensified study of the clinical and age differences between schizophrenia and epilepsy.

The difference between two diseases and in the duration (on the criteria ICD-9) of psychotic states also attracted attention. Only the frequency of the appearance of the continuously current psychoses in both groups was approximately identical (in 34,4% of cases with the schizophrenia and in 26% of cases with epilepsy). However, in the frequency of the appearance of transitory (in 1,6% of cases with the schizophrenia and in 34,7% of cases with epilepsy), and also paroxismal (respectively – in 67 and 39,6% of cases) psychoses had reliable differences. With the latter facts, apparently, it is possible to connect predominance in the population of the patients with schizophrenia cases of diseases with the total number of hospitalizations of more than 10.

The essential differences between the groups of patients studied by us were established on the level of the education obtained by them. Among the patients with schizophrenia more frequently encountered the persons with primary and secondary education, and the patients with epilepsy more frequently obtained only elementary education.

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In this connection the special interest for us was the comparison of the general data about the professional level of patients in the period until the establishment in them of the group of disablement, and also about the degree of the invalidization of patients and the nature of their working employment for the period of investigation. In the absence of reliable differences on the number of skilled workers, among those suffered schizophrenia with the stage of the disease, when yet has not been noted a professional decrease, more frequently were recorded specialists, but among the patients with epilepsy – unskilled workers.

For the period of investigation the disablement of all groups with epilepsy with the psychosis was established in 73,3% of cases, with the schizophrenia – in 56,1% of cases. To the reliable predominance of disabled in the group of the patients with epilepsy corresponded to the large gravity of the groups of the disablement: the first group of disablement more frequently was established with epilepsy. At the same time patients with epilepsy more frequently than the patients with schizophrenia, are considered as the invalids of the third group, which was, possibly, connected with the limitations in the selection of profession because of the presence of paroxysmal disorders.

In light of given data somewhat unexpected proved to be the practically identical results of studying the nature of the actual working employment of the patients with epilepsy and with schizophrenia on the period of investigation in the spheres of labor. In each of the inspected groups the working unemployment of patients was noted almost in half of the cases (in 46,3% of the cases of schizophrenia and 47,1% of cases of epilepsy). However, the employment of patients under the specially created conditions of production respectively was equal to only 10,9 and 8,8% of cases, while employment under the usual production conditions composed 42,8 and 41,1% of cases.

There was established the nonuniformity of the distribution of the types of the course of disease in the studied populations. If the favorable course of disease almost in the identical measure was encountered with schizophrenia and epilepsy (approximately in third of cases in that and other group), then the so-called average rate of progressive course proved to be more typical for the schizophrenia – in half of the cases, and the unfavorable course of disease – for epilepsy – in third of cases.

As in schizophrenia, in epilepsy appeared the reliable connections between the type of the course of disease and the register of the

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leading productive psychopathological disorders. At the same time in both groups almost completely there were no correlations between the type of the course of disease and the formation of patients, and only somewhat more frequent they were established between the type of the course of disease and the profession. However, in the greatest measure with the type of the course of disease occurred connected to the group of disablement and the nature of the working employment of patients to the period of inspection.

With the favorable course of schizophrenia and epilepsy in the structure of psychoses predominated affective disturbances, disablement more frequently was not established, and patients in majority worked in the usual labor. For the cases with the middle rate of progressive course of schizophrenia and epilepsy there was typical the predominance in the structure of the psychoses of delusional manifestations. It turned out, however, that this circumstance was the reason for complete working unemployment of the patients with more frequent epilepsy than with the schizophrenia, although the patients with schizophrenia more frequently recognized as the invalids of the second group. With the unfavorable flow of pathologic process both with the schizophrenia and with epilepsy to the equal degree predominated the psychoses with the presence of catatonic disorders, those, who carried out unskilled physical labor, before the disease equally predominated, the invalids of the first and second groups evenly were distributed, in the identical measure of characteristic for the period of inspection was the working unemployment of patients.

Revealed thus in the course of an epidemiological study heterogeneity of the dynamic interrelation of clinical and social factors made it possible to assume that in general the adaptive possibilities of patients depended on structure not only positive, but on the structure of the later emerging negative psychopathological syndromes.

The dynamic and structure analysis of psychopathological disorders with two diseases made it possible to confirm the validity of a such assumption. Furthermore, together with the clinical similarity of productive psychopathological syndromes were revealed the specific differences in the nature of the combinations of the latter with the negative symptoms, whose structure actually not only determined the nosologic uniqueness of the compared groups of patients, but also indicated the specific phasic nature in the development of schizophrenic and epileptic defects.

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The comparison of the types of the course of disease with the nature of emotional-volitional disturbances with the schizophrenia and with the structure of personality with epilepsy made it possible to reveal some regularities. In both cases to the favorable course of disease more frequently corresponded the absence of the clinically expressed signs of defect. For the middle rate of progressive course schizophrenia characteristically had the predominance in the patients emotional disorders, the disorders of thinking, syndrome of monotonic rigidity, while for the analogous type of the course of epilepsy – patients have symptoms of epileptic dementia with a prevalence of explosive reactions or symptoms of bradyphrenia. With the unfavorable course of schizophrenic process emotional-volitional defect occurred reliably more frequently, while epileptic dementia with the predominance of bradyphrenia and mnestico-intellectual disorders is more frequently established with unfavorably elapsing epilepsy.

Obtained data indicates the existence of the specific differences in the continuum of negative psychopathological manifestations with the schizophrenia and epilepsy. According to the degree of gravity the negative disorders, which corresponded to the rate of progressive course of pathologic processes, can be built in the following two rows.

With the schizophrenia: the absence of the clinically expressed signs of defect; emotional disorders (impoverishment of emotional reactions, their inadequacy, sensitivity, hyperthymism, pretentiousness, autism and other); the disorder of thinking (diffusion, tendency toward empty reasonings, readiness for the super-valuable formations, paranoiac ideas); the syndrome of monotonic rigidity (stereotypic robot-like behavior, perseverance in achieving of the narrowly set goal and other); emotional-volitional defect (apathy, passiveness, inactivity, “thoughtlessness”, absence of purposefulness of behavior, foolishness, schizophasia, the pathology of drives and other).

In epilepsy – there are no clinically significant signs of epileptic dementia (retention of critical functions with the presence of characterological or personal changes); epileptic dementia with the predominance of explosive reactions; epileptic dementia with the predominance of the syndrome of bradyphrenia; epileptic dementia with the predominance of mnestico-intellectual disorders.

The verifications of assumption, are the separate components of the represented series of psychopathological syndromes the successive stages of united process, can be devoted a special clinicocatamnestic study. Here, on the basis of epidemiological data,

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we can say that a particular type of the disease largely corresponds to a specific type of formed defect.

The results of the conducted investigation make it possible to assume that the isomorphism of productive psychopathological symptomatology in schizophrenia and epilepsy is caused, first of all, by localization of pathologic processes in each cases in the analogous functional systems of the brain (G.N. Kryzhanovskiy, 1981), connected possibly with the similar autoimmune processes (S.F. Semenov et al., 1973; V.A. Potapov et al., 1987). This, and also the fact of almost uniform distribution in both populations of the patients leading productive psychopathological disorders (affective, delusional, catatonic), testify the universality and steadiness of the basic types of psychotic reaction to the pathologic process, which, however, to no extent exclude the nosologic independence of schizophrenic and epileptic psychoses.

In recent years, arising from epidemiological studies was established a close relationship between the level of mental health and the state of immune homeostasis. If the various contingents of the population of clinical syndromes secondary immune deficiency are revealed in 15-39% of cases, the group of persons with mental health problems of varying degrees of severity – in 70-80% of cases. They provides numerous data on the presence of significant neuroimmune disorders in epilepsy. In this case it is noted that the deep and steadfast disturbances of the mechanisms of regulation and interactions of immunocompetent cells in the process of immune response are the characteristic property of the immunodependent diseases with the chronic course. (T.P. Vetlugina, 2002; L.V. Lipatova, 2010).

The need for further follow-up targeted to structural-dynamic aspect of the data in the study of the dynamics and negative symptoms in schizophrenia and epilepsy should be emphasized.

It oppears also the need for the verification of the revealed differences in clinical and social prognosis in schizophrenia and epilepsy by the corresponding results of laboratory investigations. These differences are, apparently, caused by the more expressed compensating possibilities in schizophrenia, which, probably, are connected with the preferred localization of schizophrenic process in the cortical divisions the tendency toward the generalization of the defeat of brain, while noted with epilepsy tendency can be explained by the fact that the pathologic process from the very beginning affects its deep (phylogenetically more ancient) divisions.

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Apparently, from this point of view it can be examined the established in recent years on the representative material fact of the earlier debut of schizophrenia (on the average 26,6, n=612) dependent on age, in comparison with the debut of psychotic disorders with epilepsy (on the average 30,1 of year, n=282) dependent on age (N. Adachi et al., 2008).

According to the observations of M.O. Abdulghani et al. (1997), worsening in the personal and behavioral regulation is more greatly expressed with epilepsy in patients with focal EEG by dysrhythmia. Behavioral problems in patients with epilepsy J.K. Austin et al. (1997), and also D. Besana et al. (1997) connected with “basic neurologic disfunction”. E. Baeta et al. (1997) considers necessary the search of “epileptic focus, which lies at the basis of multifocal and diffuse disorders”. A. Berger et al. (1997) connected the presence of focal seizures in children up to the two-years-old with the poor prognosis.

The repeatedly mentioned in the past idea of the conditionality of the epileptic psychoses and their frequencies by localization of pathologic process in the temporal lobe and in this case the fact of their appearance 10-15 years after the beginning of the active course of disease are confirmed in recent years by data of studies by E.J. Clarke et al. (1997), R Collinge (1997), H. Holthausen (1997), M. Inami et al. (1997), R. Manchanda et al. (1997) and others.

It should also be noted that, according to the data of L. Kalinina (1997), based on electroencephalographic studies, “symptomatic origin” of temporal lobe epilepsy is established in 74-78% of observations. At the same time “focal cortical dysplasia”, according to O. Kanazawa et al. (1997), even with frontal lobe epilepsy is favorable in prognostic sense.

Since old times the noted signs of the seasonal swings in activity of the course of some somatical and neurologic illnesses are the object of study within the framework so called of chronobiology and chronomedicine (T. Halberg, 1969; A.P. Dubrov, 1971; N.I. Moiseeva, 1975; A.A. Mikhaylenko et al., 1986). However, the attempts to reveal the statistically reliable data about the cyclic recurrence of the development of chronic psychic illnesses, commensurate with such time parameters as year, season, month, as a rule, prove to be little productive (V.V. Kolobov, 1982; G.T. Sonnik et al., 1984; U. Mueller et al., 1984).

This circumstance is, apparently, the inevitable consequence of linear approach to the study of the wide spectrum of clinico-diag-

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nostic traits, characteristic to the majority of the nosologic forms, entering the circle of psychic illnesses. One of the prerequisites of reaching the positive results of studies in this direction, probably, can prove to be the complex application of an clinico-epidemiological method and methods of course psychiatry, which synthesize the possibility of clinico-social diagnosis and prognosis.

The establishment of the reliable nosologic and prognostic differences between schizophrenia and epilepsy was the purpose of the work carried out by us in 1988, that are manifested in the presence of the seasonality of the aggravations of disease, which are repeated in separate patient twice and more times during the year, and also the seasonality of the aggravations of disease, which are repeated in patients in the different years in the same months.

The material of experiment served the total of all cases of the hospitalization for the aggravations of disease (n=3705), which occurred during disease in two not selective groups of the patients: 451 patients with schizophrenia and 329 patients with epilepsy, which takes place with the psychosis. Each patients lived in one and the same district and were observed in one and the same psychoneurological dispensary. In the card of epidemiological experiment, besides the data about the duration of disease (on the average of 25-30 years), was included the information about type and stage of the course of disease, leading psychopathological syndromes, dates of hospitalizations.

The types of the course of the disease were selected in accordance with the tasks of work as the tool of experiment: favorable, middle rate of progressive course and unfavorable, criteria of which, related to epilepsy, were represented in previous chapters.

As it was assumed, the undifferentiated comparison of the number of hospitalizations in the studied nosologic groups of patients in general proved to be little effective in the plan of the identification of facts of the confinement of the greatest frequency of the aggravations of disease, required stationary treatment, to a particular time of year. It was possible to note only the reliable decrease of the total number of aggravations in March with the schizophrenia in general. However, in epilepsy were not revealed reliable differences in the frequency of the aggravations neither from time of year nor from the months.

At the same time with the distribution of the sum of the hospitalizations of all inspected patients with schizophrenia and with epilepsy according to the types of the course of disease, proved to be possible to reveal not only specific data relating to each disease individually,

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